Immediate Discontinuation of Lamictal and Emergency Evaluation Required
This patient must discontinue Lamictal immediately and be evaluated urgently for Stevens-Johnson syndrome (SJS), as the combination of mouth sores (mucosal erosions) and fever represents a potentially life-threatening drug reaction that requires emergency intervention. 1
Critical Recognition of Drug Emergency
Lamotrigine carries a specific warning that it must be discontinued at the first appearance of mucosal erosions or other signs of hypersensitivity, as these are hallmark features of SJS and other severe cutaneous adverse reactions. 2
The incidence of serious rash with lamotrigine is 0.1% in bipolar disorder studies, and SJS typically presents within the initial weeks of treatment or during dose escalation with fever, oral erosions, and skin lesions. 3, 4, 5
Stevens-Johnson syndrome involves immune-mediated keratinocyte apoptosis and can progress to life-threatening complications including seizures, arrhythmias, and death if lamotrigine is not immediately discontinued. 5
Immediate Management Algorithm
Step 1: Drug Discontinuation (Within Hours)
Stop lamotrigine immediately—do not wait for confirmatory testing or specialist consultation, as delay increases morbidity and mortality risk. 1, 5
Do not attempt to taper lamotrigine in this scenario; abrupt discontinuation is mandatory when SJS is suspected. 1
Step 2: Emergency Assessment (Same Day)
Evaluate for extent of mucosal involvement (oral, ocular, genital erosions) and skin lesions (targetoid macules, erythematous lesions, blistering). 5
Obtain temperature, assess for systemic symptoms (malaise, arthralgia), and examine for signs of end-organ involvement. 5
Laboratory evaluation should include complete blood count, inflammatory markers (CRP, ESR), liver function tests, and renal function to assess severity and guide management. 5
Step 3: Risk Stratification
Apply SCORTEN assessment to predict mortality risk and determine need for intensive care or burn unit transfer. 5
Patients with fever plus mucosal erosions require hospital admission for monitoring and supportive care. 5
Definitive Treatment Approach
Systemic corticosteroids are the mainstay of treatment for confirmed SJS, along with antihistamines, antibiotics for secondary infection prevention, and topical agents for symptomatic relief. 5
Supportive care includes fluid management, wound care, pain control, and nutritional support until re-epithelialization occurs. 5
Multidisciplinary management involving dermatology, ophthalmology, and critical care improves outcomes in severe cases. 5
Mood Stabilizer Transition Strategy
Once the acute reaction resolves, lamotrigine must never be restarted in this patient—rechallenge carries unacceptable risk of more severe reaction. 2, 1
For ongoing bipolar disorder management, transition to alternative mood stabilizers: lithium or valproate are first-line options recommended by the American Academy of Child and Adolescent Psychiatry. 1
Lithium shows superior evidence for maintenance therapy and provides additional anti-suicide benefits (reducing suicide attempts 8.6-fold), making it an excellent alternative. 1
Critical Pitfalls to Avoid
Never adopt a "wait and see" approach with mucosal erosions and fever in lamotrigine-treated patients—this combination mandates immediate action. 2, 5
Do not confuse this presentation with benign viral stomatitis; the presence of fever with oral lesions in a patient on lamotrigine is SJS until proven otherwise. 5
Avoid prescribing lamotrigine to first-degree relatives of this patient, as genetic predisposition (HLA-B*1502 in certain populations) increases SJS risk. 5, 6
Do not restart lamotrigine after resolution "at a lower dose"—any rechallenge is contraindicated and potentially fatal. 1, 6
Patient Education and Documentation
Document the adverse reaction thoroughly and ensure it is flagged as a severe drug allergy in all medical records. 5
Educate the patient that lamotrigine and structurally similar anticonvulsants are permanently contraindicated. 6
Provide written instructions about signs of worsening reaction (increased skin involvement, respiratory symptoms, vision changes) that require immediate emergency department return. 5